Tuesday, 19 January 2010

Conservative Public Health Green Paper: Part 2

Last week, I wrote about the Conservative plans on the NHS, including their plans for public health. This is the second part of my analysis of their new public health policy.

More Evidence of Cameron Privatising the NHS

Any policy from David Cameron's Conservatives will always have a substantial amount of privatisation built in. This is the case with their policy on public health. Public health should be about benefiting the public, but the Conservatives just cannot help making sure that their friends in the private sector get the biggest benefits.

Early on in the policy document they give a fairly innocuous statement.

"Local directors of public health will manage budgets and will be obliged to commission local bodies, like schools, businesses, councils and GPs, to promote healthy living. With money behind them, they will have the power to recruit and pay innovative local organisations, whether businesses or charities, to start to implement new ways of promoting healthy choices and behaviour."

Reading this more carefully, note that public health money will be going to "businesses or charities" but not to existing NHS providers. Yet again, this indicates the lack of commitment that the Conservatives have in existing NHS providers. When the budget is restricted (a "ring-fence" does not mean unlimited cash, in fact, it means the opposite) it means that increased funding to "businesses or charities" means less funding for existing NHS providers: a cut.

So these "businesses", what will they be responsible for?

"Whenever possible, we will ensure that national public health initiatives funded by public money are paid for on the basis of the results they achieve. … By paying organisations running national campaigns by the results they achieve, we can encourage such innovation and improve the value we get from the money spent on public health."

From this statement it appears that these new private providers will be in charge of national campaigns, and hence since the responsibilities will be large, they will receive substantial amounts of public money: substantial amounts of public money going to private providers.

The Conservatives also intend to devolve some public health responsibilities to local authorities. Of course, since most local authorities are Conservative this means that the decisions that will be made will be those sanctioned by the Conservative Party's working party on health. In other words, the same policy as the Conservative Secretary of State.

"Local directors of public health will manage budgets and will be obliged to partner with local bodies, like schools, businesses, councils and GPs, to promote healthy living. And with real money behind them, they will have the power to recruit and pay innovative local organisations, like businesses and charities, to design new ways of promoting healthy choices and behaviour. To encourage a new market in innovative public health solutions is opened up in every part of the country, we will require local public health directors to ensure that an increasing proportion of contracts are awarded to providers from the private and voluntary sectors."

There is that phrase again, "businesses and charities", and no mention of existing NHS providers like hospitals. The intention is very clear from the statement "To encourage a new market" that the private sector is welcome, but the public sector is not. But note the last sentence: "we will require local public health directors to ensure that an increasing proportion of contracts are awarded to providers from the private and voluntary sectors". If you were not convinced before about the Conservative plans for privatisation of public health provision then you should be now, since it is here in black and white. Not only a "proportion" of contracts would be awarded to private providers, but an "increasing proportion", a proportion that will presumably rise to 100%. In my previous blog on this topic I identified that this section of the NHS currently has a budget of £3 billion. The Conservative plan is to hand over £3 billion to the private sector, which is £3 billion less funding for the NHS. So when David Cameron claims that he will "not cut the NHS", it is a bare-face lie, he is planning at least a 2.5% cut from day one.

Another policy is targeting funding for "deprived communities":

"So the public health funding we devolve will – subject to the results achieved - work in such a way as to give relatively bigger future funding streams to deprived communities, where health problems tend to be much worse: this is our 'Health Premium'."

Note the "subject to the results achieved" proviso, in other words, there is no guarantee of a "Health Premium". This means that providers will be reluctant about the amount of work they are willing to do, because if they do not have a guarantee that their costs will be covered they will not be willing to do the work. It is unclear how private providers will handle this situation. Private companies are always reluctant to perform work where there is no guarantee return on investment, so it is possible that this proviso "subject to the results achieved" will be watered down (and perhaps removed altogether) to encourage private providers to bid. One thing is clear, such a kid-glove approach will not be given to NHS providers because the intention is to squeeze NHS providers out of the public health "market" entirely (that is what the phrase "increasing proportion" of contracts to private providers means).

The policy document further explains what the "Health Premium" means:

"To incentivise local communities and providers to engage in improving the health of the people who live in each area, we will first establish a picture of the health of a community. The incentive system will then reward communities and providers which make progress improving public health against a set of outcomes."

Ugh, first try and get past that horrible America business-speak: "incentivise", it is the sort of phrase commonly used in US healthcare corporations, and it does give you a clue about the pedigree of these policies. So the Conservative policy "will first establish a picture of the health of a community" which presumably will establish some "objective" that local public health providers will have to achieve to get their "Health Premium". So there will be some "objectives" or "benchmarks" or maybe we can call them "targets"? Remember, this is the party that says they will "scrap all of the politically-motivated process targets", and yet here the Conservatives are saying that they will create their own targets.

From my analysis of the draft manifesto we have already seen that the Conservative policy is to re-introduce the failed GP fundholding scheme, but for public health, their policy document gives an interesting statement:

"we will develop the system that determines GPs' income, including fee-for-service and the Quality and Outcomes Framework, to align incentives with preventative health interventions, aiming to reduce people's need for more serious treatment"

What does "fee-for-service" sound like to you?

Also, think about what the phrase "aiming to reduce people's need for more serious treatment" means in practice. When a patient has a condition they need treatment, and the choice of treatment should be made solely on clinical grounds. The last time the Conservatives introduced GP fundholding the outcome was that fundholders referred fewer patients for specialist treatment than non-fundholders. It was clear at the time that if you needed specialist treatment it was better for you if your GP was a non-fundholder, than if they were a fundholder. The Conservatives want us to return to a system where referrals to specialists will be rationed.

"We will want the providers engaged by the Department to undertake such activity to be paid by results"

There is that hint of wholesale privatisation that flows throughout the Conservative health policy, these "providers… paid by results", who are these providers, again?

"we will go further by publishing the results of all public health programmes online, along with tools which allow people to compare and benchmark performance … spurring new providers to take over or replace failing programmes."

Note again the "new providers" phrase who will "take over or replace failing programmes". Presumably these "failing" providers are the NHS providers whose budget have been handed over to the "new providers". This is a bold statement. Elsewhere in their health policy documents the Conservative have been coy about how the "new providers" will get their business. However, here is a bold statement saying that they will be "spurred" to "take over or replace" NHS providers. This is the wholesale privatisation that infects Conservative health policies. Yet again, there is no commitment to existing NHS providers, if the Conservatives were committed to NHS providers they would have a plan to help them improve. There is no such plan in any of the Conservative policy documents.

"We want to harness all this innovation to revolutionise our public health approach and we will use payment by results to ensure the adoption of programmes which have been successful elsewhere. This will be one of the driving forces through which we will ensure all our activity is focused on achieving real benefits for people: national public health initiatives commissioned by the Department of Public Health funded by public money will be paid for on the basis of the results they achieve wherever possible."

The glaring problem with this approach is that it is the "new providers" that the policy document is so very keen about, who will be rewarded; it is not people and patients who will be rewarded. So rather than "real benefits for people" it will be real profits for businesses.

The Conservative policy document cites an example: "health and life insurers offer free gym membership to increase their customers' fitness". This is clearly a benefit for the customer. However, look at the plan from the Conservatives, "payment by results" (note the deliberately misleading use of the term that is the name of the current funding mechanism for hospitals) does not provide benefits to people (ie tax payers), instead it channels financial benefits from the NHS budget into private providers.

Finally, there are worrying signs that a Conservative government will force some levels of privatisation by making employers responsible for the health of their employees:

"Any economic incentive scheme needs to recognise this by helping employers to see the benefits more immediately, or by splitting the costs between all parties who benefit - the employer, the individual, and the (NHS)"

Note that these healthcare costs are split three ways. They are not free-at-the-point-of-delivery healthcare; they are healthcare where the employer and the employee will be expected to contribute. This will effectively put a tax upon employers, who in response will covertly choose not to employ people who have existing healthcare problems, or less healthy lifestyles. Conversely, once an employee has found an employer that will contribute, it will mean that the employee will be reluctant to change employer, curtailing movement in the jobs market.

The Conservative Green Paper on Public Health is important because it is one of the few documents from the Conservative party that admits that their intention is to privatise large portions of the NHS. This document shows no commitment at all to existing NHS providers. Furthermore, it brazenly says that the Conservatives will "encourage a new market in innovative public health solutions … we will require local public health directors to ensure that an increasing proportion of contracts are awarded to providers from the private and voluntary sectors". This openly admits that the private sector will be used in preference to NHS providers to the point that NHS providers will be squeezed out. Finally, the Conservatives say that their policies are intended to "[spur] new providers to take over or replace failing programmes". This is privatisation, pure and simple.